Reining in the Pain

Persistent pain poses a challenge for both athlete and athletic trainer. But by following an organized approach, you can get the athlete back in the game pain-free.

By Craig Denegar

Craig Denegar, PhD, ATC, PT, is Associate Professor in the Departments of Orthopaedics and Rehabilitation and Kinesiology, and the Director of the Undergraduate Athletic Training Program, Penn State University.

Injury and illness are a part of everyone’s day-to-day life. They can, however, be especially stress provoking and disruptive for athletes. Weeks, months, or even years of preparation and sacrifice can be scuttled by an ill-timed injury or illness that leaves an athlete unable to compete or, sometimes, simply train properly.

Fortunately, most injured athletes respond well to treatment and return to competition within a predictable time frame. For some, however, it may be a different story. Treatment may fail entirely or, more often, leave such athletes experiencing pain lasting beyond the normal time required for tissue repair and maturation, often without an identifiable pathology. Others seem to heal completely only to have the pain or injury recur repeatedly.

These scenarios can be extremely frustrating for both the treating clinician and the athlete. Is an underlying condition or injury being missed? Are these problems due to a failure to heal? Does pain linger even though healing has occurred?

First, I’d like to define persistent pain. Many people use the term chronic pain, but this connotes a condition that defies conventional interventions—no matter what you do, the athlete will continue to feel the pain. Persistent pain, on the other hand, is a lingering symptom signaling that something is wrong, but, with appropriate evaluation and treatment, the condition will resolve.

It’s also important to define pain itself. There is a certain amount of discomfort, and even pain, that all athletes train and compete through. Pain requiring treatment we define as discomfort that alters normal movement.

If someone comes into your athletic training room immediately after spraining an ankle, the injury evaluation and treatment course are fairly straightforward. With persistent pain, however, the cause is usually unknown to the athlete and may date back several months or even years.

The challenge is getting at the root of what’s causing the pain and then applying the appropriate treatment. At the same time, you will have to carefully manage the stress and frustration that many athletes feel when dealing with pain that has eluded treatment. He or she may question the abilities of—or direct his or her frustration toward—members of the sports medicine team. Clinicians may even question their own abilities. But with an organized evaluation that addresses each potential cause of the symptoms, the athlete with persistent pain can be effectively treated.

Getting at the RootThe causes of persistent pain span a spectrum from physical to principally psychological. Possible physical causes involve a failure to fully diagnose the problem, a failure to correct underlying biomechanical stresses or kinetic dysfunction, an inappropriate plan of treatment, or a rest-reinjury cycle.

In addition, the athlete could be affected by a complex regional pain syndrome or myofascial pain syndrome. The causes of these syndromes are complicated and not fully understood, but the possibility that the source of pain lies proximal or distal to the injured tissues must also be explored. Stress can contribute to or exacerbate these conditions.

Physical pain can also be a symptom of psychological stress and depression. Somatization—somatic pain of psychological origins—may also result in persistent pain.

In my experience, the most common causes of persistent pain in the competitive athlete are an inappropriate treatment plan coupled with a rest-reinjury cycle, a failure to correct faulty biomechanics related to dysfunction along a kinetic chain, and the failure to recognize a myofascial pain pattern. These are not the sole causes of persistent pain, but the ones you will most likely be confronted with. Taking a closer look at these causes will give a good idea of how to go about assessing and treating an athlete with persistent pain.

Rest-Reinjury CyclesThere is a tendency for those who treat musculoskeletal injuries to focus solely on the injured area. Following a knee injury involving a meniscal tear, for example, the diagnostic testing and subsequent surgical intervention focus on the damaged structure and the involved joint. Post-operatively, the physical therapist or athletic trainer will tend to focus on the impairments associated with the injury and surgical procedure, such as pain, swelling, loss of motion, and loss of quadriceps-force-generating capacity.

This process usually suffices for the patient who will return to a relatively sedentary lifestyle or gradually resume a fitness-based exercise regimen. The competitive athlete, however, may lose a considerable amount of sport-specific conditioning if his or her overall fitness is not addressed during the rehabilitation plan of care.

From the injured athlete’s perspective, the resolution of impairments and the ability to resume training often imply that the injured tissues have healed and a return to competition is near. In an effort to quickly return to training, many athletes will train at a level for which they have not reconditioned. The training overload results in greater breakdown than they can recover from and reinjury occurs.

Keeping the athlete out of this rest-reinjury cycle requires a cooperative effort on the part of the sports medicine team and the injured athlete. The members of the sports medicine team must understand the demands of the athlete’s sport and develop a rehabilitation plan that minimizes the loss of cardiovascular, neuromuscular, and sport-specific fitness. The athlete, meanwhile, must appreciate that the reduction of symptoms does not mean that he or she has fully reconditioned and is ready to return to his or her sport.

Two concepts can help the athlete avoid a rest-reinjury cycle. The first is the “exercise intensity window.” I have found this concept very useful in helping an athlete through sport-specific reconditioning following injury. At the start of any season or new training program, the body has not developed a tolerance to high-intensity or long-duration efforts. If the athlete exceeds his or her limits, injury and breakdown can occur. Through training, he or she develops greater tolerance to exercise and an ability to work harder for longer periods of time. Following injury, however, the athlete’s tolerance to exercise can regress toward preseason levels. The more severe the injury and the longer the recovery, the greater the effect.

The second concept is a simple rule to follow during this late phase of rehabilitation: the athlete should be able to repeat tomorrow what was done today. If too sore from the previous day’s workout to perform the same exercises, he or she has pushed it too far and needs to cut back. The athlete progresses by slowly adding exercises and drills but, at this stage, not to the extent that one day’s training will keep him or her from being able to complete the next day’s training.

From this basis, the exercise program can progress so that exercise intensities requiring more than one day of recovery are introduced. The program can be individualized and progressed as per the athlete’s tolerance, but it is better to do too little initially than experience reinjury and a prolonged recovery.

Biomechanics andKinetic DysfunctionTaking a myopic view of an injury can not only contribute to ineffective plans of care and reinjury, but can also lead to a failure to identify and correct faulty mechanics and kinetic chain dysfunctions. A swimmer, for example, may present with shoulder pain and a diagnosis of rotator cuff tendinitis. Physical examination may reveal weakness of the rotator cuff musculature. A restriction of swimming activities and a rotator cuff strengthening program will likely result in a resolution of symptoms and strength gains in the targeted musculature. If, however, the swimmer has developed a poor stroke pattern (such as low recovery during freestyle, which could be a compensation for an injury that has since resolved) and repeatedly places the shoulder in an impinging position, the shoulder pain will persist until the underlying cause or poor mechanics is identified and dealt with.

Similarly, an athlete with persistent patellofemoral pain who fails to respond to a program of quadriceps retraining may suffer from unrecognized weakness in the gluteus medius resulting in excessive internal rotation and poor patellar tracking. Until recognized and treated, the problem will persist.

The list of kinetic dysfunctions that can lead to injury elsewhere in the kinetic chain is almost limitless. Dr. Ben Kibler has identified the role of the scapula in optimal functioning of the shoulder and arm during the throwing motion (“The Role of the Scapula in Athletic Shoulder Function.” Am J Sports Med, 1998;26:325). Improper tracking caused by muscle imbalances or faulty biomechanics can lead to a host of conditions. Another common fault, excessive subtalar pronation, is linked to a list of conditions, including plantarfasciitis, Achilles tendinitis, patellofemoral pain, and medial tibial stress syndrome.

When treating an athlete with persistent pain, the sports medicine team must assess the entire kinetic chain in isolation and during functional activities. Unrecognized dysfunction is untreated dysfunction. A failure to address the possibility that the source of persistent pain involves faulty movement mechanics will result in a failure to resolve the pattern of persistent pain.

Myofascial PainPersistent pain may also originate from muscle and fascial tissues. This complex phenomenon is not fully understood and can be difficult to treat. Myofascial pain syndrome is characterized by tender, taut bands of connective tissue referred to as either tender or trigger points. (While tender points are in themselves painful areas, trigger points radiate or refer pain or other sensation to another area of the body. For more information on myofascial pain, see “Beyond Stretching,” in T&C 10.2, March 2000; for more on trigger points, see “Targeting Trigger Points,” T&C 10.7, October 2000.) Tender points are commonly found bilaterally in the cervical and thoracic regions and over the trapezius. They can, however, be found practically anywhere in the upper and lower extremities.

Myofascial pain presents a unique challenge in that there are no specific diagnostic tests for the condition, nor is there a single cause. Trauma, repetitive microtrauma, muscle imbalances, poor posture, psychological stress, and illness can contribute to myofascial pain patterns, especially in the trunk and neck. Myofascial pain patterns in the extremities tend to be related more to repetitive microtrauma and muscle imbalances.

The mechanism by which the underlying trigger points develop is also not fully understood. One possible explanation suggests that their development stems from an increase in gamma efferent activity resulting in heightened sensitivity of a muscle spindle to stretch. When excessive stretch is sensed at the spindle, efferent impulses from the spindle to the dorsal horn of the spinal cord result in stimulation of alpha motor neurons with subsequent contraction of the affected muscle. The muscle is then held in a state of increased tone and, over time, the surrounding fascia adapts and shortens. The palpable taut bands are likely due to these fascial adaptations.

It is unclear exactly what spurs the increase in gamma efferent activity, although noxious or painful stimulation is a very likely source. But once tender points develop, they can be further sensitized by increased muscle tension due to stress or fatigue associated with repetitive tasks or illness.

Effective treatment of myofascial pain requires desensitization of the tender or trigger points and management of the contributing factors. A gradual reconditioning to address muscle imbalances and reintroduce the demands of sport is required. If not addressed, exercise simply exacerbates the persistent, myofascial pain pattern.

A Management SchemeRegardless of whether the athlete was initially evaluated elsewhere or in-house, or was never fully evaluated, the first step in treatment is a thorough assessment or reassessment. This should begin, as would any examination, with a complete history and physical examination. The possibility of alternative diagnoses should be explored. If the original diagnosis continues as the most probable cause of the athlete’s symptoms, then the plan of care should be carefully reviewed and the potential contributions of kinetics dysfunction or mechanical flaws explored. Patterns of rest-reinjury must be identified and addressed.

If no new information is gleaned at this point, the athlete should be evaluated for myofascial pain syndrome. Only after these sources of persistent pain are ruled out should the possibility of psychosomatic disorders, including clinical depression and somatization, be considered.

Following the re-evaluation pro-cess, appropriate adjustments in the plan of care should be made, with the inclusion of precise and realistic short- and long-term treatment goals. These goals allow for continual reassessment as well as a means for the clinician and athlete to track progress. Short- and long-term goals need to be mutually agreeable to the athlete and the sports medicine team. They also need to be realistic and achievable, while progressing toward the athlete’s ultimate goals. This will help motivate the athlete and deal with some of the frustration he or she will likely be feeling over the nagging injury.

In many cases, athletes are solely focused on the long-term goal of returning to competition. When progress is slow, they fail to recognize that they have, in fact, improved. Achievement of short-term goals can bolster their commitment to the long-term plan of care.

Communication and patient education is essential in the treatment of persistent pain. The psychological response to injury is modified through cognitive appraisal. While each athlete copes with injury in his or her own way, a greater understanding of the nature of the injury and the recovery will greatly assist him or her through the recovery process.

An Active roleWhen treating persistent pain, it is important to make the athlete take an active role in his or her rehab. Make the athlete understand that he or she is the one with the injury. While the members of the sports medicine team are trained to evaluate and treat the injury, the athlete must know that it is his or her responsibility to follow instructions regarding medication, protection of the injured tissues, and appropriate therapeutic exercise.

The athlete must also be encouraged to continually communicate with the members of the sports medicine team. He or she must understand that even though the plan of care was chosen because of its success in managing a particular condition in other athletes, it may not achieve the goals for him or her. You may have to explain to the athlete that while re-evaluation is warranted, he or she must effectively communicate that he or she has followed instructions and still has not been able to achieve treatment goals in a timely manner.

It is also important that the injured athlete and members of the sports medicine team have a realistic estimate of the time required to achieve specific goals. Unfortunately, the body’s tissues do not know when the big game is. Tissue repair and reconditioning take time and, despite advances in sports medicine, the ability to speed recovery is limited.

The final dose of reality is that some bodies are not made to, or are no longer capable of, withstanding the demands of some sports. Variations in tissue and anatomical structure may preclude training at a level sufficient for success in a particular sport. An adolescent with congenital laxity at the shoulders may not be able to train sufficiently to succeed in swimming. The older runner with articular cartilage damage in his or her knee may no longer be able to run competitively—or at all.

Both the sports medicine team and the athlete must accept the reality that there are some conditions for which effective treatment is not available. The inability to continue to participate in a sport is stressful and requires a lifestyle adjustment. Unfortunately, it is sometimes the only way to resolve persistent pain.

For the majority of young athletes, however, persistent pain can be treated. By following an organized evaluation and treatment course, and getting at the root of the problem, most athletes can make a full return to their sport pain-free.

All of the articles from Training & Conditioning mentioned above can be found on our Web site, at www.AthleticSearch.com. Simply search for key words, such as “massage,” or “myofascial pain.”